Cefadroxil tablets induced-drug hypersensitivity syndrome complicated with acute myocarditis and death

A 61-year-old female patient took cefadroxil tablets 0.5 g twice daily herself due to fever after blepharorrhaphy in her right eye. Her temperature returned to normal, but the medication was not discontinued and 2 weeks later, the patient developed skin rash on her limbs with severe itching, and fever (39 ℃). Then cefadroxil tablets were stopped but her symptoms were gradually aggravated, and then facial swelling appeared 5 days later. On the seventh day of onset, she was admitted to the hospital, with white blood cell count 25×109/L, percentage of eosinophils 0.29, eosinophil count 7.4×109/L, and normal liver and kidney function, myocardial enzymes, and electrocardiogram. Antiallergic and symptomatic treatments were given after the admission. On day 4 of admission, the patient developed dizziness and general fatigue. Her blood pressure was 96/61 mmHg and her heart rate was 110 beats per minute. The electrocardiogram showed multilead ST segment elevations and the echocardiography revealed a small amount of pericardial effusion. Laboratory tests showed that the cardiac troponin T (cTnT) was 1.52 μg/L, creatine kinase (CK) was 236 U/L, CK-MB was 63 U/L, and N-terminal pro-brain natriuretic peptide (NT-proBNP) was 9 708 ng/L. The patient was diagnosed with drug hypersensitivity syndrome complicated with acute myocarditis and pericarditis. Intravenous infusion of high dose methylprednisolone (500 mg/d), human immunoglobulin (40 g/d), and myocardial nutrition treatments were given. On day 5 of admission, the patient was transferred to the cardiovascular care unit (CCU), when her blood pressure was 80/50 mmHg, CK was 498 U/L, CK-MB was 98 U/L, cTnT was 5.33μg/L, and left ventricular ejection fraction was 55%. However, the patient′ myocarditis and pericarditis progressed rapidly. On day 3 in the CCU, the laboratory tests showed CK 1 252 U/L, CK-MB 231 U/L, cTnT 4.57 μg/L, NT-proBNP 17 979 ng/L, and left ventricular ejection fraction 10%, which then decreased to 5% on day 6. Finally, the patient died on day 9 in the CCU. Key words: Cefadroxil; Drug hypersensitivity syndrome; Myocarditis; Death